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SURGICAL ANATOMY by Joseph Maclise

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Plate 46--Figure 3

Plate 46--Figure 4

Plate 46--Figure 5

COMMENTARY ON PLATE 47.

THE SURGICAL DISSECTION OF THE PRINCIPAL BLOODVESSELS AND

NERVES OF THE ILIAC AND FEMORAL REGIONS.

Through the groin, as through the axilla, the principal blood vessels and nerves are transmitted to, the corresponding limb. The main artery of the lower limb frequently becomes the subject of a surgical operation. The vessel is usually described as divisible into parts, according to the regions which it traverses. But, as in examining any one of those parts irrespective of the others, many facts of chief surgical importance are thereby obscured and overlooked, I propose to consider the vessel as a whole, continuous from the aorta to where it enters the popliteal space. The general course and position of the main artery may be described as follows:--The abdominal aorta, A, bifurcates on the body of the fourth lumbar vertebra. The level of the aortic bifurcation corresponds with the situation of the navel in front, and the crista ilii laterally. The aorta is in this situation borne so far forwards by the lumbar spine as to occupy an almost central position in the cavity of the abdomen. If the abdomen were pierced by two lines, one extending from a little to the left side of the navel, horizontally backwards to the fourth lumbar vertebra, and the other from immediately over the middle of one crista ilii, transversely to a corresponding point in the opposite side, these lines would intersect at the aortic bifurcation. The two arteries, G G,* into which the aorta divides symmetrically at the median line, diverge from one another in their descent towards the two groins. As both vessels correspond in form and relative position, the description of one will serve for the other.

While the thigh is abducted and rotated outwards, if a line be drawn from the navel to a point, D, of the inguinal fold, midway between B, the anterior iliac spine, and C, the symphysis pubis, and continued thence to the inner condyle of the femur, it would indicate the general course of the artery, G I W. In this course, the vessel may be regarded as a main trunk, giving off at intervals large branches for the supply of the pelvic organs, the abdominal parietes, and the thigh. From the point where the vessel leaves the aorta, A, down to the inguinal fold, D, it lies within the abdomen, and here, therefore, all operations affecting the vessel are attended with more difficulty and danger than elsewhere, in its course.

The artery of the lower limb, arising at the bifurcation of the aorta on the fourth lumbar vertebra, descends obliquely outwards to the sacra-iliac junction, and here it gives off its first branch, G, (internal iliac,) to the pelvic organs. The main vessel is named common iliac, at the interval between its origin from the aorta and the point where it gives off the internal iliac branch. This interval is very variable as to its length, but it is stated to be usually two inches. The artery, I, continuing to diverge in its first direction from its fellow of the opposite side, descends along the margin of the true pelvis as far as Poupart's ligament, D, where it gives off its next principal branches,-- viz., the epigastric and circumflex iliac. At the interval between the internal iliac and epigastric branches, the main artery, I, is named external iliac; and the surgical length of this part is also liable to vary, in consequence of the epigastric or circumflex iliac branches arising higher up or lower down than usual. The main vessel, after passing beneath the middle of Poupart's ligament, D, next gives off the profundus branch, N, to supply the thigh. This branch generally arises at a point an inch and half or two inches below the fold of the groin; and between it and the epigastric above, the main artery is named common femoral. From the point where the profundus branch arises, down to the popliteal space, the vessel remains as an undivided trunk, being destined to supply the leg and foot. In this course, the artery is accompanied by the vein, H K O, which, according to the region in which it lies, assumes different names, corresponding to those applied to the artery. Both vessels may now be viewed in relation to each other, and to the several structures which lie in connexion with them.

(Page 105)

106

COMMENTARY ON PLATE 47.

The two vessels above Poupart's ligament lie behind the intestines, and are closely invested by the serous membrane. The origin of the vena cava, F, lies close to the right side of the bifurcation of the aorta, A; and here both vessels are supported by the lumbar spine. Each of the two arteries, G G,* into which the aorta divides, has its accompanying vein, H, on its inner side, but the common iliac part of the right artery is seen to lie upon the upper portions of both the veins, as these joining beneath it form the commencement of the vena cava. The external iliac part, I, of each artery has its vein, K, on its inner side. At the point, G, where the artery gives off its internal iliac branch, the ureter, g, crosses it, and thence descends to the bladder. The internal iliac branch subdivides in general so soon after its origin, that it may be regarded as for the most part an unsafe proceeding to place a ligature upon it.

The iliac vessels, A G I, in approaching Poupart's ligament along the border of the true pelvis, are supported by the psoas muscle, and invested and bound to their place by the peritonaeum, and a thin process of the iliac fascia. Some lymphatic glands are here found to lie over the course of the vessels. The spermatic artery and vein, together with the genito-crural nerve, descend along the outer border of the iliac artery. When arrived at Poupart's ligament, the iliac vessels, I K, become complicated by their own branches, and also by the spermatic vessels, as these are about to pass from the abdomen through the internal inguinal ring. While passing beneath the middle of Poupart's ligament, D, the iliac artery, I, having its vein, K, close to its inner side, rests upon the inner border of the psoas muscle, and in this place it may be effectually compressed against the os pubis. The anterior crural nerve, P, which in the iliac region lies concealed by the psoas muscle, and separated by this from the vessels, now comes into view, lying on the outer side of the artery. When the vessels have passed from beneath Poupart's ligament, the serous membrane no longer covers them, but the fibrous membrane is seen to invest them in the form of a sheath, divided into two compartments, one of which (internal) receives the vein, the other the artery. The iliac vessels, in passing to the thigh, assume the name of femoral.

The femoral vessels, O N W, in the upper third of the thigh traverse a triangular space, the base of which is formed by Poupart's ligament, D, whilst the sides and apex are formed by the sartorius, Q, and adductor longus muscles, T, approaching each other. In the undissected state of the part, the structures which bound this space can in general be easily recognised. A central depression extends from the middle of its base, D, to its apex, V, and marks the course of the vessels. Near the middle of Poupart's ligament, the vessels are comparatively superficial, and here the artery may be felt pulsating; but lower down, as they approach the apex of the triangle, the vessels become gradually deeper, till the sartorius muscle inclining from its origin obliquely inwards to the centre of the thigh, w, at length overlaps them. The inner border of the sartorius muscle at the lower part of the upper third of the thigh, W, guides to the position of the artery. Whilst traversing the femoral triangle, the vessels enclosed in their proper sheath are covered by the fascia lata, adipose membrane, and integument. In this place they lie imbedded in loose cellular and adipose tissue. The femoral vein, O, is on the same plane with the artery near Poupart's ligament; but from this place downwards through the thigh, the vein gradually winds from the inner to the back part of the artery; and when both vessels pass under cover of the sartorius, they enter a strong fibrous sheath, V, derived from the tendons of the adductor muscles upon which they lie. The artery approaches the shaft of the femur near its middle; and in this place it may be readily compressed against the bone by the hand. The anterior crural nerve, P, dividing on the outer side of the artery, sends some of its branches coursing over the femoral sheath; and one of these--the long saphenous nerve--enters the sheath and follows the artery as far as the opening in the great adductor tendon. The femoral artery, before it passes through this opening into the popliteal space, gives off its anastomatic branch.

COMMENTARY ON PLATE 47.

107

The profundus branch, N, springs from the outer side of the femoral artery usually at a distance of from one to two inches (seldom more) below Poupart's ligament, and soon subdivides. [Footnote] The femoral artery in a few instances has been found double.

[Footnote: The ordinary length of each part of the main artery is stated on the authority of Mr. Quain. See "Anatomy of the Arteries," &c. ]

The main artery of the lower limb may be exposed and tied in any part of its course from the aorta to the popliteal space. But the situation most eligible for performing such an operation depends of course upon circumstances, both anatomical and pathological. If an aneurism affect the popliteal part of the vessel, or if, from whatever cause arising, it be found expedient to tie the femoral above this part, the place best suited for the operation is that where the artery, W, first passes under cover of the sartorius muscle. [Footnote] For, considering that the vessel gives off no important branch destined to supply any part of the thigh or leg between the profundus branch and those into which it divides below the popliteal space, the arrest to circulation will be the same in amount at whichever part of the vessel between these two points the ligature be applied. But since the vessel in the situation specified can be reached with greater facility here than elsewhere lower down; and since, moreover, a ligature applied to it here will be sufficiently removed from the profundus branch above, and the seat of disease below, to produce the desired result, the choice of the operator is determined accordingly. The steps of the operation performed at the situation W, where the artery is about to pass beneath the sartorius, are these: an incision of sufficient length--from two to three inches--is to be made over the course of the vessel, so as to divide the skin and adipose membrane, and expose the fascia lata, through which the inner edge of the sartorius muscle becomes now readily discernible. A vein (anterior saphena) may be found to cross in this situation, but the saphena vein proper is not met with, as this lies nearer the inner side of the thigh. The fascia having been next divided, the edge of the sartorius is to be turned aside, and now the pulsation of the artery in its sheath will indicate its exact position. The sheath is next to be opened, for an extent sufficient only to carry the point of the ligature-needle safely around the artery, care being taken not to injure the femoral vein, which lies close behind it, and also to exclude any nerve which may lie in contact with the vessel.

[Footnote: This is the situation chosen by Scarpa for arresting by ligature the circulation through the femoral artery in cases of popliteal aneurism. The reasons stated in the text are those which determine the surgeon to perform the operation in this place in preference to that (the lower third of the thigh) where Mr. Hunter first proposed to tie the vessel.]

108

COMMENTARY ON PLATE 47.

If an aneurism affect the common femoral portion of the artery, the external iliac part would require to be tied, because, between the seat of the tumour and the epigastric and circumflex ilii branches above, there would not be sufficient space to allow the ligature to rest undisturbed; and even if the aneurism arose from the femoral below the profundus branch in the upper third of the thigh, or if, after amputation of the thigh, a secondary haemorrhage took place from the femoral and the profunda arteries, a ligature would with more safety be applied to the external iliac part than to the common femoral; because of this latter, even when of its clear normal length, presenting so small an interval between the epigastric and profundus branches. In addition to this, it must be noticed, that occasionally the profundus itself, or some one of its branches, (external and internal circumflex, &c.), arises as high up as Poupart's ligament, close to the origin of the epigastric and circumflex iliac. [Footnote]

[Footnote: The main artery (Plate 47) has been exposed in the iliac and femoral regions with the object of showing the relation which its parts bear to each other and to the whole; all the other dissections have been made upon the same plan, the practical tendency of which will be illustrated when considering the subject of arterial anastomosis.]

The external iliac part of the artery, G I, when requiring to be tied, may be reached in the following way: an incision, commencing above the anterior iliac spine, B, is to be carried inwards parallel to, and above, Poupart's ligament, D, as far as the outer margin of the internal abdominal ring. This incision is the one best calculated for avoiding the epigastric artery, and for not disturbing the peritonaeum more than is necessary. The skin and the three abdominal muscles having been successively incised, the fibrous transversalis fascia is next to be carefully divided, so as to expose the peritonaeum. This membrane is then to be gently raised by the fingers, from off the iliacus and psoas muscles as far inwards as the margin of the true pelvis where the artery lies. On raising the peritonaeum the spermatic vessels will be found adhering to it. The iliac artery itself is liable to be displaced by adhering to the serous membrane, when this is being detached from the inner side of the psoas muscle. [Footnote] The artery having been divested of its serous covering as far up as a point midway between I G, the epigastric and internal iliac branches, the ligature is to be passed around it in this place, as being equidistant from these two sources of disturbance. As the vein, K, lies close along the inner side of the artery, the point of the instrument should first be inserted between them, and passed from within outwards, in order to avoid wounding the vein. If an aneurism affect the upper end of the external iliac artery, it is proposed to tie the common iliac; but this is an operation of so serious a nature, that it can in this respect be exceeded only by tying the aorta itself. The common iliac artery is so situated, that it can as easily be reached from the groin upwards as from the side of the abdomen inwards, and in both directions the peritonaeum would have to be disturbed to an equal extent.

[Footnote: The student, in operating upon the dead subject, is often puzzled to find that the iliac artery does not appear in its usual situation, unaware at the time that he has lifted the vessel in connexion with the peritonaeum. I have once seen a very distinguished surgeon, whilst performing this operation on the living body, at fault owing to the same cause.]

DESCRIPTION OF PLATE 47.

A.The aorta at its point of bifurcation.

B.The anterior superior iliac spine.

C.The symphysis pubis.

D.Poupart's ligament, immediately above which are seen the circumflex ilii and epigastric arteries, with the vas deferens and spermatic vessels.

E E*. The right and left iliac muscles covered by the peritonaeum; the external cutaneous nerve is seen through the membrane.

F. The vena cava.

G G*. The common iliac arteries giving off the internal iliac branches on the sacro-iliac symphyses; g g, the right and left ureters.

H H*. The right and left common iliac veins.

I I*. The right and left external iliac arteries, each is crossed by the circumflex ilii vein.

K K *. The right and left external iliac veins.

L.The urinary bladder covered by the peritonaeum.

M.The rectum intestinum.

N.The profundus branch of the femoral artery.

O.The femoral vein; 0, the saphena vein.

P.The anterior crural nerve.

Q.The sartorius muscle, cut.

S.The pectinaeus muscle.

T.The adductor longus muscle.

U.The gracilis muscle.

V.The tendinous sheath given off from the long adductor muscle, crossing the vessels, and becoming adherent to the vastus internus muscle.

W.The femoral artery. The letter is on the part where the vessel becomes first covered by the sartorius muscle.

Plate 47.

COMMENTARY ON PLATES 48 & 49.

THE RELATIVE ANATOMY OF THE MALE PELVIC ORGANS.

As the abdomen and pelvis form one general cavity, the organs contained in both regions are thereby intimately related. The viscera of the abdomen completely fill this region, and transmit to the pelvic organs all the impressions made upon them by the diaphragm and abdominal walls. The expansion of the lungs, the descent of the diaphragm, and the contraction of the abdominal muscles, cause the abdominal viscera to descend and compress the pelvic organs; and at the same time the muscles occupying the pelvic outlet, becoming relaxed or contracted, allow the perinaeum to be protruded or sustained voluntarily according to the requirements. Thus it is that the force originated in the muscular parietes of the thorax and abdomen is, while opposed by the counterforce of the perinaeal muscles, brought so to bear upon the pelvic organs as to become the principal means whereby the contents of these are evacuated. The abdominal muscles are, during this act, the antagonists of the diaphragm, while the muscles which guard the pelvic outlet become at the time the antagonists of both. As the pelvic organs appear therefore to be little more than passive recipients of their contents, the voluntary processes of defecation and micturition may with more correctness be said to be performed rather for them than by them. The relations which they bear to the abdomen and its viscera, and their dependence upon these relations for the due performance of the processes in which they serve, are sufficiently explained by pathological facts. The same system of muscles comprising those of the thorax, abdomen and perinaeum, performs consentaneously the acts of respiration, vomiting, defecation and micturition. When the spinal cord suffers injury above the origin of the phrenic nerve, immediate death supervenes, owing to a cessation of the respiratory act. Considering, however, the effect of such an injury upon the pelvic organs alone, these may be regarded as being absolutely excluded from the pale of voluntary influence in consequence of the paralysis of the diaphragm, the abdominal and perinaeal muscles. The expulsory power over the bladder and rectum being due to the opposing actions of these muscles above and below, if the cord be injured in the neck below the origin of the phrenic nerve, the inferior muscles becoming paralysed, the antagonism of muscular forces is thereby interrupted, and the pelvic organs are, under such circumstances, equally withdrawn from the sphere of volition. The antagonism of the abdominal muscles to the diaphragm being necessary, in order that the pelvic viscera may be acted upon, if the cord be injured in the lower dorsal region, so as to paralyse the abdominal walls and the perinaeal muscles, the downward pressure of the diaphragm alone could not evacuate the pelvic organs voluntarily, for the abdominal muscles are now incapable of deflecting the line of force backwards and downwards through the pelvic axis; and the perinaeal muscles being also unable to act in agreement, the contents of the viscera pass involuntarily. Again, as the muscular apparatus which occupies the pelvic outlet acts antagonistic to the abdomen and thorax, when by an injury to the cord in the sacral spine the perinaeal apparatus alone becomes paralysed, its relaxation allows the thoracic and abdominal force to evacuate the pelvic organs involuntarily. It would appear, therefore, that the term "paralysis" of the bladder or rectum, when following spinal injuries, &c. &c. means, or should mean, only a paralytic state of the abdomino-pelvic muscular apparatus, entirely or in part. For, in fact, neither the bladder nor rectum ever acts voluntarily per se any more than the stomach does, and therefore the name "detrusor" urinae, as applied to the muscular coat investing the bladder, is as much a misnomer (if it be meant that the act of voiding the organ at will be dependent upon it) as would be the name "detrusor" applied to the muscular coat of the stomach, under the meaning that this were the agent in the spasmodic effort of vomiting.

(Page 109)

110

COMMENTARY ON PLATES 48 & 49.

The urinary bladder, G, Plate 49, (in the adult body,) occupies the true pelvic region when the organ is collapsed, or only partly distended. It is situated behind the pubic symphysis and in front of the rectum, C,--the latter lies between it and the sacrum, A. In early infancy, when the pelvis is comparatively small, the bladder is situated in the hypogastric region, with its summit pointing towards the umbilicus; as the bladder varies in shape, according to whether it be empty or full, its relations to neighbouring parts, especially to those in connexion with its summit, vary also considerably. When empty, the back and upper surface of the bladder collapse against its forepart, and in this state the organ lies flattened against the pubic symphysis. Whether the bladder be distended or not, the small intestines lie in contact with its upper surface, and compress it in the manner of a soft elastic cushion. When distended largely, its summit is raised above the pubic symphysis, the small intestines having yielded place to it, and in this state it can be felt by the hand laid upon the hypogastrium.

The shape of the bladder varies in different individuals. In some it is rounded, in others pyriform, in others peaked towards its summit. Its capacity varies also considerably at different ages and in different sexes. When distended, its long axis will be found to coincide with a line passing from a point midway between the navel and pubes to the point of the coccyx, the obliquity of this direction being greatest when the body is in the erect posture, for the intestines now gravitate upon it. When the body is recumbent, the bladder recedes somewhat from the pubes, and as the intestines do not now press upon it from above, it allows of being distended to a much greater degree without causing uneasiness, and a desire to void its contents.

The manner in which the bladder is connected to neighbouring parts is such as to admit of its full distension. Its summit, back, and upper sides are free and covered by the elastic peritonaeum, whilst its front, lower sides, and base are adherent to adjacent parts, and divested of the serous membrane. On tracing the peritonaeum from the front wall of the abdomen to its point of reflexion over the summit of the bladder, we find the membrane to be in this part so loosely adherent, that the bladder when much distended, raises the peritonaeum above the level of the upper margin of the pubic symphysis. In this state the organ may be punctured immediately above the pubic symphysis without endangering the serous sac. When the bladder is collapsed, the peritonaeum follows its summit below the level of the pubes, and in this position of the organ such an operation would be inadmissible, if indeed the necessity for it can now be conceived.

By removing the os innominatum, A D, Plate 48, together with the internal obturator, and levator ani muscles, which arise from its inner side, we obtain a lateral view, Plate 49, of the pelvic viscera, and of the vessels &c. connected with them. Those parts of the bladder, G, and the rectum, C, which are invested by the peritonaeum, are also now fully displayed. On tracing this membrane from before backwards, over the summit of the bladder, G, we find it descending deeply upon the posterior surface of the organ, before it becomes reflected so as to ascend over the forepart of the rectum. This duplicature of the serous membrane, H H, is named the recto-vesical pouch, and it is required to ascertain with all the exactness possible the level to which it descends, so as to avoid it in the operation of puncturing the bladder through the rectum. The serous pouch descends lower in some bodies than in others; but in all there exists a space, of greater or less dimensions, between it and the prostate, V, whereat the base of the bladder is in direct apposition with the rectum, W, the serous membrane not intervening.

When the peritonaeum is traced from one iliac fossa to the other, we find it sinking deeply into the hollow of the pelvis behind the bladder, so as to form the sides of the recto-vesical pouch; but when traced over the summit of the bladder, this organ is seen to have the membrane reflected upon it, almost immediately below the pelvic brim. At the situations where the peritonaeum becomes reflected in front, laterally, and behind, upon the sides of the bladder, the membrane is thrown into folds, which are named "false ligaments."

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